Citation Nr: 1315070 Decision Date: 05/07/13 Archive Date: 05/15/13 DOCKET NO. 08-06 375 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Newark, New Jersey THE ISSUES 1. Entitlement to service connection for bilateral hearing loss. 2. Entitlement to service connection for tinnitus. 3. Entitlement to an increased disability evaluation (rating) in excess of 20 percent for degenerative changes in the lumbar spine. 4. Entitlement to an increased disability evaluation (rating) in excess of 10 percent for a status post meniscal and lateral tear of the right knee and chronic cruciate ligament for the period prior to August 22, 2012, and 20 percent thereafter. 5. Entitlement to an initial disability evaluation (rating) in excess of 30 percent for posttraumatic stress disorder (PTSD) for the period prior to August 15, 2012, and 70 percent thereafter. 6. Entitlement to a total disability rating based on individual unemployability (TDIU). REPRESENTATION Appellant represented by: National Association of County Veterans Service Officers WITNESS AT HEARING ON APPEAL The Veteran (Appellant) ATTORNEY FOR THE BOARD Hallie E. Brokowsky, Counsel INTRODUCTION The Veteran served on active duty from May 1984 to May 1994 and from February 2003 to January 2004 and he had additional service with the Air Force Reserves. This matter comes on appeal before the Board of Veterans' Appeals (Board) from October 2006, October 2008, and June 2010 rating decisions of the Department of Veterans Affairs (VA) Regional Office in Newark, New Jersey (RO). In an October 2006 rating decision, the RO denied service connection for bilateral hearing loss and tinnitus, and continued a 20 percent evaluation for degenerative changes of the lumbar spine. In an October 2008 rating decision, the RO granted a 10 percent rating for a status post meniscal and lateral tear of the right knee and chronic cruciate ligament effective December 5, 2005. The Board notes that the Veteran is additionally in receipt of a separate 10 percent evaluation for arthritis of the right knee. In a June 2010 rating decision, the RO granted service connection for PTSD and assigned a 30 percent evaluation effective September 11, 2007. The Veteran testified at a November 2011 travel Board hearing; the hearing transcript has been associated with the claims file. The Board has not only reviewed the Veteran's physical claims file, but also the Veteran's file on Virtual VA, to ensure a total review of the available evidence. This case was previously before the Board in April 2012, wherein it was remanded for additional VA examinations and to obtain VA treatment records. The case was returned to the Board for appellate consideration. The Board finds that there has been substantial compliance with the directives of the remand, as the Veteran was afforded VA examinations and the requested VA treatment records were obtained. As such, an additional remand to comply with such directives is not required. See Stegall v. West, 11 Vet. App. 268 (1998). Subsequently, in an October 2012 rating decision, the RO increased the Veteran's disability evaluation for his PTSD to 70 percent disabling, effective August 15, 2012, and the rating for his status-post medial meniscal and lateral tear of the right knee, with instability and chronic cruciate ligament, to 20 percent disabling, effective August 22, 2012. The grant of a higher initial rating is not a full grant of the benefit sought on appeal. See AB v. Brown, 6 Vet. App. 35 (1993). Further development of the evidence is required before the Board can adjudicate a pending claim for a TDIU. As such, the claim for TDIU is being remanded to the RO via the Appeals Management Center (AMC) in Washington, DC. FINDINGS OF FACT 1. The Veteran does not have bilateral hearing loss disability for VA compensation purposes. 2. The Veteran's tinnitus had its onset in service and is causally related to his military service. 3. Throughout the entire rating period, the Veteran's degenerative changes of the lumbar spine was productive of pain with range of forward flexion of the thoracolumbar spine to 60 degrees. 4. Throughout the entire rating period, the Veteran's status-post right knee medial meniscus and lateral tear with instability and chronic cruciate ligament has been manifested by moderate recurrent subluxation and lateral instability. 5. Throughout the initial rating period on appeal, the Veteran's PTSD has been characterized by occupational and social impairment with difficulties in most areas, such as work, family relations, judgment, and mood, due to near continuous depression affecting the ability to function independently, impaired impulse control, and difficulty in adapting stressful circumstances. CONCLUSIONS OF LAW 1. Bilateral hearing loss disability was not incurred in active service, and may not be presumed to have been incurred in service. 38 U.S.C.A. §§ 1110, 1112, 1154, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309 (2012). 2. Tinnitus was incurred in active military service. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2012). 3. The criteria for a disability rating greater than 20 percent for degenerative changes of the lumbar spine have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5235 - 5243, 4.124a, Diagnostic Codes 8520, 8620 (2012). 4. The criteria for an increased disability evaluation of 20 percent, but no higher, for status-post meniscal and lateral tear of the right knee with instability and chronic cruciate ligament have been met for the entire period on appeal. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002); 38 C.F.R. §§ 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5257 (2012). 5. The criteria for an initial disability evaluation of 70 percent, but no higher, for PTSD have been met for the entire period on appeal. 38 U.S.C.A. §§ 1155, 5103A, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.126, 4.130, Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). The United States Court of Appeals for Veterans Claims (CAVC) issued a decision in the appeal of Dingess v. Nicholson, 19 Vet. App. 473 (2006), which held that the notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim, including the degree of disability and the effective date of an award. Those five elements include: (1) veteran status; (2) existence of a disability; (3) a connection between a veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. In this case, the agency of original jurisdiction (AOJ) issued notice letters, dated in November 2005, August 2006, November 2007, and June 2008, to the Veteran. These letters explained the evidence necessary to substantiate the Veteran's claims for service connection and increased ratings, as well as the legal criteria for entitlement to such benefits. The letters also informed him of his and VA's respective duties for obtaining evidence. The AOJ decision that is the basis of this appeal was decided after the issuance of an initial, appropriate VCAA notice. As such, there was no defect with respect to timing of the VCAA notice. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). VA also has a duty to assist a veteran with the development of facts pertinent to the appeal. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c). This duty includes the obtaining of "relevant" records in the custody of a Federal department or agency under 38 C.F.R. § 3.159(c)(2), as well as records not in Federal custody (e.g., private medical records) under 38 C.F.R. § 3.159(c)(1). VA will also provide a medical examination if such examination is determined to be "necessary" to decide the claim. 38 C.F.R. § 3.159(c)(4). In this case, the claims file contains the Veteran's service treatment records and reports of VA and private post-service treatment, as well as the Veteran's own statements in support of his claims. The Veteran was examined by VA in connection with his claims for increased ratings for his spine and right knee disabilities, as well as his PTSD, in 2005, 2006, 2007, 2008, 2009, 2010, and 2012. He was also examined in connection with his claims for service connection for bilateral hearing loss and tinnitus in 2009 and 2012. The Board has reviewed the examination reports, and finds that they are adequate for the purpose of deciding the issues on appeal. The examination reports contain all the findings needed to rate the Veteran's service-connected disabilities and evaluate the claims for service connection, including his history and clinical evaluation. The Board has reviewed the Veteran's statements and medical evidence of record and concludes that there is no outstanding evidence with respect to the Veteran's claims. The Veteran's appeal for higher evaluations is distinguished from the facts in Proscelle v. Derwinski, 2 Vet. App. 629, 633 (1992), where no VA examination was provided during the rating claim, and a veteran specifically stated that his disability "has increased in severity [such] that I rate a higher disability," constituting at least both some assertion by the veteran and some evidence of worsening of disability since the last VA examination. Proscelle, 2 Vet. App. at 632. In the Veteran's case currently on appeal to the Board, there is no evidence of worsening of the Veteran's disability since the 2012 VA examinations, including no assertion by the Veteran of worsening since the last VA examinations. The Veteran here does not assert that his disabilities have worsened since the July 2012 and August 2012 VA examinations; he merely asserts entitlement to higher disability evaluations. The Veteran has not submitted evidence of worsening, and the evidence of record, including the medical evidence reflecting on the severity of the disability on appeal, does not suggest that the disability on appeal has worsened since the last VA examination and VA treatment records in 2012. As there is no evidence of worsening since the last VA examination, a remand for a new VA examination is not warranted, and is not required by the VCAA. See Palczewski v. Nicholson, 21 Vet. App. 174, 182 (2007) (mere passage of time does not require VA to provide a new medical examination); VAOPGCPREC 11-95 (interpreting that a new examination is appropriate when there is an assertion of an increase in severity since the last examination). The Veteran has been afforded adequate examinations on the issues decided herein. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). For these reasons, the Board finds that the VCAA duties to notify and assist have been met. Legal Criteria for Service Connection It is the Board's responsibility to evaluate the entire record on appeal. See 38 U.S.C.A. § 7104(a) (West 2002). In this case, the Board has thoroughly reviewed all the evidence in the Veteran's claims folder. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, all of the evidence submitted by a veteran or on his or her behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). When there is an approximate balance in the evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. The Court held that an appellant need only demonstrate that there is an "approximate balance of positive and negative evidence" in order to prevail. See Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). The Court has also stated, "It is clear that to deny a claim on its merits, the evidence must preponderate against the claim." Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert. In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert, supra, 1 Vet. App. at 57. Service connection may be granted for disability or injury incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection for a disability on the basis of the merits of such claim requires (1) the existence of a current disability; (2) the existence of the disease or injury in service, and; (3) a relationship or nexus between the current disability and any injury or disease during service. Hickson v. West, 12 Vet. App. 247, 253 (1999), citing Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996). In addition, the law provides that, where a veteran served ninety days or more of active service, and certain chronic diseases, such as organic diseases of the nervous system, become manifest to a degree of 10 percent or more within one year after the date of separation from such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 2002); 38 C.F.R. §§ 3.307, 3.309(a) (2012). While the disease need not be diagnosed within the presumption period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree during that time. Id. The Veteran's claimed bilateral hearing loss is an organic disease of the nervous system, which is listed as a "chronic disease" under 38 C.F.R. § 3.309(a); however, as discussed below, the Veteran does not meet the criteria for VA compensation purposes. Therefore, 38 C.F.R. § 3.303(b) does not apply. Lay assertions may serve to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. See 38 U.S.C.A. § 1153(a) (West 2002); 38 C.F.R. § 3.303(a); see also Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) and Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). In certain circumstances, however, lay evidence may be sufficient to establish a medical diagnosis or nexus. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). Service connection may be established on a secondary basis for a disability that is proximately due to or the result of a service-connected disease or injury. See 38 C.F.R. § 3.310(a) (2012); Harder v. Brown, 5 Vet. App. 183, 187 (1993). Additional disability resulting from the aggravation of a nonservice-connected condition by a service-connected condition is also compensable under 38 C.F.R. §3.310(a). See Allen v. Brown, 7 Vet. App. 439, 448 (1995). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). For VA purposes, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz is 40 decibels or greater; the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, and 4000 Hertz are 26 decibels or greater; or speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. Additionally, the United States Court of Appeals for Veterans Claims (Court) has held that "the threshold for normal hearing is from 0 to 20 dBs [decibels], and higher threshold levels indicate some degree of hearing loss." See Hensley v. Brown, 5 Vet. App. 155, 157 (1993). Analysis of Service Connection Hearing Loss The Veteran seeks service connection for bilateral hearing loss. In multiple statements, and at the 2009 and 2012 VA examinations, the Veteran reported that he was exposed to excessive noise due to a lack of proper hearing protection while working with an aeromedical evacuation unit during Operation Iraqi Freedom. He also asserted that he continued to have hearing difficulties since service. After a review of all the evidence, the Board finds that, while the Veteran had exposure to acoustic trauma during service, he does not have current bilateral hearing loss disability for VA compensation purposes (38 C.F.R. § 3.385). The Board finds that the Veteran was exposed to loud noise (acoustic trauma) during service. The Veteran reported a history of military noise exposure due to service, and his DD Form 214 (Armed Forces of the United States Report of Transfer or Discharge) states that the Veteran's military occupational specialty was medical service in the Air Force. According to the Veteran, he had in-service noise exposure due to aircraft noise without proper hearing protection, and in connection with other assigned duties. As such, the Board finds that exposure to acoustic trauma in service is consistent with the circumstances of his service. 38 U.S.C. § 1154(a) (West 2002). However, the evidence of record does not demonstrate that the Veteran has sufficient hearing loss in both his left and right ears to meet the threshold minimum requirements of 38 C.F.R. § 3.385 to be considered an actual hearing "disability" by VA disability standards. The reported audiometric findings at the June 2009 and August 2012 VA examinations revealed the Veteran did not have auditory thresholds of 40 decibels or greater at the frequencies 500, 1000, 2000, 3000, or 4000 Hertz; auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, and 4000 Hertz that are 26 decibels or greater; or speech recognition scores less than 94 percent. 38 C.F.R. § 3.385. Pure tone thresholds, in decibels, at the August 2012 VA examination were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 10 5 15 15 20 LEFT 5 10 15 20 10 Speech audiometry revealed speech recognition ability was 96 percent in the right ear and 100 percent in the left ear. In this regard, the Board notes that, despite the Veteran's complaints, the record does not reflect that the Veteran has any current hearing loss which meets the thresholds required for a grant of service connection. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992) ("Congress specifically limits entitlement to service-connected disease or injury to cases where such incidents have resulted in a disability."). See also Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000) (a Veteran seeking disability benefits must establish the existence of a disability and a connection between such Veteran's service and the disability). Although the Veteran is competent to report symptoms of hearing loss that he may have experienced at any time, as a layperson, he is not competent to diagnose bilateral hearing loss disability because hearing loss is an insidious process identified by objective and specific audiometric and speech recognition testing, and the potential causes of hearing loss first manifesting decades after service are potentially multi-factorial. See Jandreau v. Nicholson, 492 at 1377 (Fed. Cir. 2007). For these reasons, the Board finds that a preponderance of the evidence of record is against a finding that the Veteran has a bilateral hearing loss disability related to his service; therefore, the claim for service connection for bilateral hearing loss must be denied. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. Tinnitus The Veteran asserts entitlement to tinnitus related to noise exposure during service. As previously stated, the Veteran reported that he was exposed to excessive noise due to a lack of proper hearing protection while working with an aeromedical evacuation unit during Operation Iraqi Freedom. The Board also acknowledges that the June 2009 and August 2012 VA audiological examiners did not find that the Veteran's tinnitus could be attributed to a specific date or circumstance during the Veteran's active military service, as the Veteran had normal hearing at discharge, without complaints of tinnitus; the August 2012 VA examiner found that the etiology of the Veteran's tinnitus was not likely to be related to the Veteran's service. However, this is not determinative as to whether his current tinnitus is etiologically related to his military service and does not preclude service connection in this case. In this regard, the August 2012 VA audiological examiner based the opinion on the absence of tinnitus at the Veteran's post-deployment examination, and did not provide any reason why the Veteran's in-service acoustic trauma was not a source of his current tinnitus. The Board observes that the Veteran was exposed to noise on the flight line during his service and that the VA audiological examiner conceded that the Veteran had noise exposure during service. In this regard, the Veteran's September 2003 post-deployment examination indicates that the Veteran reported exposure to loud noise, but denied experiencing ringing of the ears. Nevertheless, the Veteran testified at the November 2011 hearing before the undersigned that he experienced intermittent ringing in the ears during his last period of active service and in the years since that last period of active service; the Board points out that the Veteran's deployment ended in September 2003, but his period of service ended in January 2004, without a separate examination. Thus, the VA examiner's opinion based on the absence of documented tinnitus at the end of the deployment does not mean that the Veteran did not have tinnitus in service or that there is no nexus between the Veteran's current tinnitus and his in-service noise exposure. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (finding that most of the probative value of a medical opinion comes from its reasoning). Indeed, the Veteran consistently and credibly contended that he experienced in-service noise exposure and that he had tinnitus in service and since service. See Layno v. Brown, 6 Vet. App. 465 (1994). Moreover, the Board finds that the examiner's negative opinion regarding tinnitus was apparently based on an erroneous assumption that service connection for this condition required a documentary showing of tinnitus in service. Based on the Veteran's credible testimony that he had tinnitus in service and since service , the evidence support a finding that tinnitus was incurred in service. Accordingly, service connection is warranted for tinnitus. Rating Disabilities Disability ratings are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. See 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. If two ratings are potentially applicable, the higher rating will be assigned if the disability more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the veteran. See 38 C.F.R. § 4.3. When an unlisted condition is encountered it will be permissible to rate under a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous. 38 C.F.R. § 4.20 (2012). A disability rating may require re-evaluation in accordance with changes in a veteran's condition. Thus, it is essential that the disability be considered in the context of the entire recorded history when determining the level of current impairment. See 38 C.F.R. § 4.1. See also Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Nevertheless, where an award of service connection for a disability has been granted and the assignment of an initial evaluation for that disability is disputed, separate evaluations may be assigned for separate periods of time based on the facts found. In other words, evaluations may be "staged." See Fenderson v. West, 12 Vet. App. 119, 125-26 (1999). This, in turn, will compensate the veteran for times since the effective date of the award when his disability may have been more severe than at other times during the course of his appeal. Additionally, where the veteran is appealing the rating for an already established service-connected condition, his present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). The Board notes that staged ratings are appropriate for an increased-rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). The United States Court of Appeals for Veterans Claims (Court) has emphasized that when assigning a disability rating it is necessary to consider functional loss due to flare-ups, fatigability, incoordination, and pain on movements. See DeLuca v. Brown, 8 Vet. App. 202, 206-7 (1995). The rating for an orthopedic disability should reflect functional limitation due to pain which is supported by adequate pathology and evidenced by the visible behavior of the veteran undertaking the motion. Weakness is also as important as limitation of motion, and a part which becomes painful on use must be regarded as seriously disabled. A little used part of the musculoskeletal system may be expected to show evidence of disuse, either through atrophy, the condition of the skin, absence of normal callosity, or the like. See 38 C.F.R. § 4.40. The factors of disability reside in reductions of their normal excursion of movements in different planes. Instability of station, disturbance of locomotion, and interference with sitting, standing, and weight bearing are related considerations. See 38 C.F.R. § 4.45. It is the intention of the rating schedule to recognize actually painful, unstable, or maligned joints, due to healed injury, as entitled to at least the minimal compensable rating for the joint. 38 C.F.R. § 4.59. Lumbar Spine The diagnostic code criteria pertinent to rating spinal disabilities are codified at 38 C.F.R. § 4.71a, Diagnostic Codes 5237 through 5243. All diseases and injuries of the spine other than intervertebral disc syndrome are to be evaluated under the general rating formula. Intervertebral disc syndrome (preoperatively or postoperatively) is to be rated either under the general rating formula or under the formula for rating intervertebral disc syndrome based on incapacitating episodes, whichever method results in the higher evaluation when all disabilities are combined under 38 C.F.R. § 4.25. 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5243. According to the general rating formula, a 10 percent evaluation is to be assigned for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or combined range of motion of the thoracolumbar spine greater than 120 degrees, but not greater than 235 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. A 20 percent evaluation is to be assigned for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent evaluation is to be assigned for forward flexion of the thoracolumbar spine 30 degrees or less; or favorable ankylosis of the entire thoracolumbar spine. A 50 percent evaluation is to be assigned for unfavorable ankylosis of the entire thoracolumbar spine. For VA compensation purposes, unfavorable ankylosis is a condition in which the entire cervical spine, entire thoracolumbar spine, or entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. 68 Fed. Reg. 51,443, Note (5) (Aug. 27, 2003). Any associated objective neurological abnormalities, including but not limited to bowel or bladder impairment, are to be evaluated separately under an appropriate DC. 68 Fed. Reg. 51,443, Note (1) (Aug. 27, 2003). The Veteran contends that he is entitled to an increased disability rating for his degenerative changes of the lumbar spine. He has reported pain with activity, along with occasional stiffness, fatigue, and spasms. After a review of all the evidence, lay and medical, the Board finds against an evaluation in excess of 20 percent for the Veteran's degenerative changes of the lumbar spine. At the December 2005 VA examination, the Veteran had flexion to 70 degrees, extension to 20 degrees, lateral flexion to 20 degrees, and rotation to 15 degrees, without additional loss of motion on repetitive use. At the September 2006 VA examination, the Veteran had forward flexion to 90 degrees, with lateral flexion to 30 degrees, full extension, and rotation to 30 degrees. Repeated movement reduced flexion to 82 degrees, but there was no increase in fatigue or weakness. There was tenderness at L3-4 and spasm, but without fixed deformity or intervertebral disc syndrome. The Veteran's degenerative changes of the lumbar spine was productive of forward flexion to 60 degrees at the July 2012 VA examination; extension at that examination was to 20 degrees, and lateral flexion and rotation was to 30 degrees. The report indicated that there was no objective evidence of pain on motion, weakness, atrophy, or guarding. There was also no evidence of postural abnormalities or abnormalities of the musculature of the thorocolumbar spine. Strength and sensory testing were normal, and he had normal motor function. There was some tenderness in the lower lumbosacral spine, without muscle spasms. The Veteran denied experiencing incontinence, bowel complaints, or erectile dysfunction. Reflexes were normal. Thus, applying the facts to the criteria set forth above, the Veteran remains entitled to no more than a 20 percent evaluation for his service-connected degenerative changes of the lumbar spine for the rating period on appeal under the General Rating Formula for Diseases and Injuries of the Spine. The Board has considered whether additional functional impairment due to factors such as pain, weakness and fatigability demonstrate additional limitation of motion or function to warrant a higher rating. See 38 C.F.R. §§ 4.40, 4.45, 4.59 and DeLuca at 206-07. To the extent that the Veteran claims that his pain upon motion is the equivalent of limited motion, the Board finds that the Veteran's subjective complaints of pain have been contemplated in the current rating assignment, as the current ratings are based on the objectively demonstrated reduced motion; the December 2005, September 2006, May 2009, and July 2012 VA examination reports indicate that the Veteran complained of pain, but physical examination did not demonstrate any additional limitations in response to pain, including incoordination, weakness, or fatigability, although the Veteran did lose 8 degrees of flexion at the September 2006 VA examination, as indicated above. The Veteran had normal reflexes bilaterally throughout the rating period. Therefore, the clinical findings do not demonstrate that the Veteran's symptoms result in additional functional limitation to a degree that would support a rating in excess of the current disability rating; the evidence reveals a disability picture most approximating a 20 percent evaluation thereafter, even with consideration of whether there was additional functional impairment due to DeLuca factors. See Mitchell, supra. Further, the evidence does not show favorable or unfavorable ankylosis of the entire thoracolumbar spine during either of the rating periods on appeal. The July 2012 VA examination explicitly noted that there was no evidence of unfavorable or favorable ankylosis. The evidence also does not show that the Veteran's degenerative changes of the lumbar spine has been productive of incapacitating episodes for either rating period on appeal. According to the July 2012 VA examination, the Veteran does not have intervertebral disc disease. Also, the July 2012 VA examination report indicates that the Veteran does not have any incapacitating episodes requiring bed rest by a physician and treatment by a physician. There is no objective evidence of neurological impairment due to the Veteran's service-connected degenerative changes of the lumbar spine for the rating period on appeal. With consideration of the provisions of Note (1) of the General Rating Formula for Diseases and Injuries of the Spine, the Board notes that there is no objective evidence of record for the entire rating period on appeal which demonstrates that the Veteran experiences any neurologic symptomatology. The medical evidence demonstrates that the Veteran's neurologic evaluations at the May 2009 and July 2012 VA examinations were normal. There was also no evidence of neurological manifestations upon VA treatment. For these reasons, the Board finds that the evidence is against a finding of neurologic manifestations of the Veteran's service-connected lumbosacral strain to warrant a separate, compensable rating under DC 8520, 8521, 8524, 8525, or 8526. Residuals of Meniscal and Lateral Tear The Veteran's status-post meniscal and lateral tear of the right knee and chronic cruciate ligament is rated as 10 percent disabling prior to August 22, 2012 and 20 percent disabling thereafter, pursuant to 38 U.S.C.A. § 4.71a, Diagnostic Code (DC) 5257. According to DC 5257, a 10 percent rating is warranted for slight subluxation or lateral instability, a 20 percent rating is warranted for moderate subluxation or lateral instability and a 30 percent rating is warranted for severe subluxation or lateral instability. The Veteran contends that a disability rating higher than 10 percent for status-post meniscal and lateral tear of the right knee and chronic cruciate ligament is warranted for the period prior to August 22, 2012 and a disability rating in excess of 20 percent is warranted thereafter. In multiple statements and at his hearing before the undersigned, the Veteran reported that he experiences pain and increasing instability of the right knee, and that he uses a cane. At the July 2008 VA examination, he reported popping, instability, clicking, locking, and swelling, as well as pain. VA treatment records show complaints of pain and occasional buckling of the right knee, but without a history of falls or assistive devices. After a review of all the evidence, lay and medical, the Board finds that for the entire rating period on appeal the Veteran's service-connected residuals of a meniscectomy of the right knee more nearly approximate the criteria for a 20 percent disability evaluation, but no higher, under Diagnostic Code 5257. The Board finds that the Veteran does not have more than slight subluxation or lateral instability. At the July 2008 VA examination, the Veteran denied using a brace or other assistive devise regularly; however, a December 2007 VA treatment record indicates that the Veteran was issued a brace in response to complaints of buckling, without falls. At the July 2008 VA examination, the Veteran had tenderness to palpation and mild effusion, with negative anterior drawer, Lachman's and McMurray's testing; upon MRI, the anterior cruciate ligament was absent. In June 2010, he complained of clicking, locking, buckling, and popping, with intermittent swelling; the Veteran reported that he had a knee brace and cane, but did not use them. Examination showed tenderness to palpation, equivocal Lachman and anterior drawer testing, and mild instability. Moreover, the Board notes that VA treatment records dated in 2011 show that the Veteran repeatedly reported experiencing buckling of his knee, although VA treatment notes indicate that use of a brace or assistive device was inconsistent. The evidence generally reflects of no more than moderate instability, and the Veteran's gait is consistently found to be antalgic. In this case, the Board finds the objective evidence is more probative than the Veteran's complaints at the VA examinations, and the Board finds the Veteran's right knee disability is productive of no more than moderate instability during the rating period. The weight of the evidence does not demonstrate additional functional impairment, above and beyond the 20 percent level, which would support an even higher rating. In this regard, the Board points out that the Veteran's June 2010 VA examination report was negative for objective evidence of incoordination, subluxation, weakness, abnormal movement, or deformity. See DeLuca, citing 38 C.F.R. §§ 4.40, 4.45, and 4.59. There was also no evidence of effusion, redness, abnormal guarding, or inflammatory arthritis, although the Veteran reports experiencing pain. Likewise, the evidence does not show decreased motor strength and x-rays did not show a fracture or dislocation. His pain did not further inhibit his range of motion or otherwise create functional limitations. The evidence does not demonstrate that he has other symptoms (e.g., premature or excess fatigability, weakness, incoordination) which otherwise result in any additional functional limitation in his right knee to a degree or extent that would support a higher rating. In particular, the July 2008, June 2010, and August 2012 VA examiners noted that there was a mild increase in pain upon repetitive use, but found that there was no additional weakness, fatigability, incoordination, lack of endurance, or additional loss of motion. As a result, his current 20 percent rating for his right knee adequately compensates him for the extent of his pain, including insofar as its resulting effect on his range of motion. Similarly, although the Veteran has pain of the right knee, but he does not have overall moderate impairment of his tibia and fibula, dislocated semilunar cartilage, or ankylosis. See 38 C.F.R. § 4.71a, Diagnostic Codes 5256, 5258, 5262. The Board also notes that the Veteran was found to have degenerative changes of the right knee, and that the Veteran now receives a separate 10 percent disability rating pursuant to 38 C.F.R. § 4.71a, Diagnostic Codes 5010-5260. The Board further notes that the Veteran has not appealed that rating. PTSD The Veteran's PTSD was initially evaluated as 30 percent disabling under 38 C.F.R. § 4.130, Diagnostic Code 9411. His PTSD was increased to 70 percent disabling, effective August 15, 2012. A 30 percent disability rating is warranted where there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks, chronic sleep impairment, and mild memory loss. See 38 C.F.R. § 4.130, Diagnostic Code 9411. Under 38 C.F.R. § 4.130, Diagnostic Code 9411, a 50 percent disability rating requires occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short-term and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. For the next higher 70 percent evaluation to be warranted, there must be occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood due to symptoms such as: suicidal ideation; obsessive rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and an inability to establish and maintain effective relationships. Id. A 100 percent rating is provided for total occupational and social impairment, due to such symptoms as: Gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. §§ 4.125-4.130. The GAF is a scale reflecting the "'psychological, social, and occupational functioning on a hypothetical continuum of mental health- illness.'" Carpenter v. Brown, 8 Vet. App. 240, 242 (1995) (quoting the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (1994) (DSM-IV)). See also 38 C.F.R. § 4.130. A GAF score of 41-50 indicates "Serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) OR any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job)." Id. A GAF score of 51-60 indicates "Moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) OR moderate difficulty in social, occupational, or school functioning, (e.g., few friends, conflicts with peers or co-workers)." Id. A GAF score of 61-70 indicates "Mild symptoms (e.g., depressed mood and mild insomnia) OR some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, has some meaningful interpersonal relationships. Id. The list of symptoms under the rating criteria are meant to be examples of symptoms that would warrant the evaluation, but are not meant to be exhaustive. The Board need not find all or even some of the symptoms to award a specific evaluation. See Mauerhan v. Principi, 16 Vet. App. 436, 442-3 (2002). On the other hand, if the evidence shows that a veteran suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the diagnostic code, the appropriate equivalent rating will be assigned. Mauerhan, 16 Vet. App. at 443. The U.S. Court of Appeals for the Federal Circuit has embraced the Mauerhan Court's interpretation of the criteria for rating psychiatric disabilities. See Sellers v. Principi, 372 F.3d 1318, 1326 (Fed. Cir. 2004). The Veteran contends that a higher initial disability rating than 30 percent for PTSD is warranted for the initial rating period on appeal, and that an increased staged rating higher than 70 percent is warranted for the period since August 15, 2012. In his notice of disagreement, the Veteran's representative asserted that the Veteran's social and occupational impairment was severe. After a review of all the evidence, lay and medical, the Board finds that the Veteran's service-connected PTSD more nearly approximates the criteria for an initial 70 percent disability evaluation, but no higher, for the entire rating period on appeal under Diagnostic Code 9411. The Board finds that the Veteran's psychiatric symptoms have been relatively consistent, and that the 70 percent evaluation takes into account the Veteran's social and occupational impairment for the entire initial rating period. Throughout the initial rating period, the Veteran's PTSD has been characterized by occupational and social impairment with deficiencies in most areas, including work, family relations, thinking, and mood due to symptoms affecting the ability to function independently, unprovoked irritability, difficulty in adapting to stressful circumstances, and an inability to establish and maintain effective relationships. The evidence shows that the Veteran does not experience panic attacks, nor does he have obsessional rituals, impaired impulse control, delusions or hallucinations, spatial disorientation, or illogical speech or thought processes as a result of his PTSD; he is alert and oriented upon examination, he does not have a hyperstartle response, and his depression and anxiety do not prevent him from functioning independently. Nevertheless, VA examiners assessed that PTSD symptoms interfered with occupational functioning and social relationships for the Veteran. The VA examiners and treating VA providers assigned GAF scores of 50 to 60 (December 2007 and November 2011), 49 (April 2011), 56 (May 2010), and 51 (August 2012) on the basis of PTSD. A GAF score is probative, as it relates directly to a veteran's level of impairment of social and industrial adaptability, as contemplated by the rating criteria for mental disorders. See Massey v. Brown, 7 Vet. App. 204, 207 (1994). A GAF score of 41-50 contemplates serious symptoms or any serious impairment in social or occupational functioning. See DSM-IV at 44-47. The Board notes that the Veteran's GAF scores of 49 and 51 are consistent with the symptomatology shown in contemporaneous treatment records. The GAF scores of the VA examiners and treating providers take into account all of the medical evidence of record, lay and objective, for the rating period on appeal, such that a fuller picture of the nature and history of the Veteran's PTSD is provided. See 38 C.F.R. § 4.2 (2012) (it is the responsibility of the rating specialist to interpret reports of examination in the light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability present). VA examination reports and treatment records indicate that the Veteran's PTSD symptoms were productive of severe occupational and social impairment, with reduced reliability and productivity. The Board acknowledges that the Veteran, through his representative, complained of severe symptoms and that his symptoms had increased such that his daily functioning was impaired. The Veteran complained of nightmares, anger, irritability, difficulty concentrating, memory loss, hypervigilance, hyperstartle response, and depression at his initial, December 2007 VA examination. A December 2007 letter from a treating psychologist at VA noted that the Veteran's symptoms included anger, irritability, anxiety, and depression. At his May 2010 and August 2012 VA examinations, he also complained of anxiety, intrusive thoughts, and some avoidance behaviors. In this case, however, these symptoms are described as severe. At the May 2010 VA examination, the Veteran had depression and anxiety, but did not have suicidal or homicidal ideation, delusions or hallucinations, or panic attacks; his mood was depressed and his affect was blunted. A November 2011 letter from a VA psychologist stated that the Veteran had difficulty with anxiety, impaired short term memory, and family, social, and work relationships; the psychologist noted that the Veteran reported anxiety, loss of sleep, hyperarousal, and avoidance. Moreover, in August 2012, the Veteran complained of depression, hypervigilance, sleep impairment, irritability, and anger. Significantly, the Veteran's VA treating provider, in the December 2007 letter, stated that the Veteran had severe PTSD symptoms, with limited work abilities due to attention and concentration problems, as well as depression, anxiety, and excessive anger. Although VA treatment notes from this same provider, dated from 2006 through 2012, indicate that the Veteran is alert and oriented, with appropriate speech and behavior, and without evidence of suicidal or homicidal ideation, the August 2012 VA examination report showed that the Veteran's PTSD symptoms have lead to a decrease in work performance; he experienced detachment and estrangement from others, a restricted affect, outbursts of anger, difficulty concentrating, difficulty adapting to stressful circumstances such as a work environment, inability to establish and maintain effective relationships, and depression. The VA examiner opined that the Veteran's PTSD symptoms caused clinically significant impairment of social and occupational functioning. In consideration of the foregoing, the Board has considered all of the Veteran's psychiatric symptoms in reaching its decision regarding entitlement to a higher rating, as they impact occupational and social impairment. The Board particularly notes that the Veteran's PTSD, standing alone, has been consistently characterized as severe. However, the Board finds that the criteria for a disability rating of 100 percent have not been met or more nearly approximated for any part of the rating period on appeal. Although several of the Veteran's treating providers, including the 2007 and 2011 letter from his treating providers at VA and the May 2010 and August 2012 VA examination reports, opined that the Veteran experiences social and occupational impairment, the evidence does not show that the Veteran experiences total occupational and social impairment due to grossly impaired thought processes, persistent delusions and hallucinations, persistent danger of hurting himself or others, or intermittent inability to perform activities of daily living, as contemplated by a 100 percent disability rating under Diagnostic Code 9411. As previously discussed, the Board acknowledges that the Veteran's PTSD symptoms are suggestive of deficiencies in work, family relations, and mood. Nonetheless, as noted in the VA examination reports, and the Veteran's VA treatment records, the Veteran's functional impairments are not so severe as to impair his thought processes; there was no evidence of delusions or hallucinations and the Veteran did not have any active or passive suicidal ideation. Further, VA treatment records are negative for evidence of psychosis; the Veteran is able to communicate effectively and he is alert, oriented, and cooperative. Additionally, the VA examination report in August 2012 shows that the Veteran did not have cognitive impairment, his speech was normal, and the examiner noted that that the Veteran was able to function effectively within certain parameters. At that time, the Veteran was able to work. Significantly, the VA providers and examiners assessed that the Veteran's service-connected PTSD was as previously characterized and was productive of severe, but not gross or totally disabling, effects on his activities of daily living. For these reasons, the Board finds that a preponderance of the evidence is against an initial disability evaluation in excess of 70 percent for PTSD for the entire period. 38 C.F.R. §§ 4.3, 4.7. Extraschedular Considerations The Board has considered whether referral for an extraschedular evaluation is warranted for his service-connected disabilities on appeal. In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321 (2012). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Therefore, initially, there must be a comparison between the level of severity and symptomatology for each of the claimant's service-connected disabilities with the established criteria found in the rating schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008). Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. In the second step of the inquiry, however, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." See 38 C.F.R. 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). When the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for completion of the third step-a determination of whether, to accord justice, the claimant's disability picture requires the assignment of an extraschedular rating. Id. Turning to the first step of the extraschedular analysis, the Board finds that the symptomatology and impairment caused by the Veteran's degenerative changes of the lumbar spine, status-post meniscal and lateral tear of the right knee and chronic cruciate ligament, and PTSD are specifically contemplated by the schedular rating criteria, and no referral for extraschedular consideration is required. The schedular rating criteria, Diagnostic Codes 5237, 5257, and 9411, specifically provide for disability ratings based on a combination of history and clinical findings. In this case, considering the lay and medical evidence, the Veteran's degenerative changes of the lumbar spine, status-post meniscal and lateral tear of the right knee and chronic cruciate ligament, and PTSD have symptoms which are part of the schedular rating criteria. Regarding the degenerative changes of the lumbar spine and status-post meniscal and lateral tear of the right knee and chronic cruciate ligament, the Veteran had complaints of pain and limitation of motion of the lumbar spine, and pain and instability of the right knee, but did not have additional functional impairment beyond that which was contemplated by the rating criteria. The Veteran had range of motion of the lumbar spine to 60 degrees, and no more than moderate instability of the right knee. Additionally, as previously discussed, the factors of 38 C.F.R. §§ 4.40, 4.45, and 4.59, as well as those in DeLuca, were adequately contemplated in the rating criteria utilized to rate the Veteran's disabilities. Likewise, the Veteran's complaints of irritability, intrusive thoughts, difficulty concentrating, and occupation and social impairment related to his PTSD are contemplated by the rating criteria. The disability rating schedule is intended to compensate for average impairments in earning capacity resulting from service-connected disability in civil occupations. See 38 U.S.C.A. § 1155. "Generally, the degrees of disability specified [in the rating schedule] are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability." 38 C.F.R. § 4.1. In this case, the problems reported by the Veteran are specifically contemplated by the criteria discussed above, including the effect on his daily life. In the absence of exceptional factors associated with degenerative changes of the lumbar spine, status-post meniscal and lateral tear of the right knee and chronic cruciate ligament, and PTSD, the Board finds that the criteria for submission for assignment of extraschedular ratings pursuant to 38 C.F.R. § 3.321(b)(1) are not met. See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). (CONTINUED ON NEXT PAGE) ORDER Service connection for bilateral hearing loss is denied. Service connection for tinnitus is granted. An increased disability evaluation (rating) in excess of 20 percent for degenerative changes in the lumbar spine is denied. An increased disability evaluation (rating) of 20 percent for status post meniscal and lateral tear of the right knee and chronic cruciate ligament is granted. An initial disability rating of 70 percent for PTSD is granted. REMAND The United States Court of Appeals for Veterans Claims (Court) held that a TDIU claim is part of an increased rating claim when such claim is raised by the record. Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). In this case, the Veteran has not formally filed a claim of entitlement to a TDIU. A February 2013 Memorandum of the RO in the claims file indicates that the RO has inferred a TDIU claim due to the mental health increased rating. The record does not indicate that the TDIU claim has been adjudicated. Evidence of record reflects on occupational impairment due to the service-connected disabilities. The Veteran reported on several occasions that he continues to work, but that his service-connected disabilities, particularly his PTSD, require accommodation and interfere with his ability to function fully on the job, as he is unable to perform all of his required duties as a result of his service-connected knee disabilities. The Veteran, at his 2012 VA PTSD examination, and in multiple statements, reported that he is still working, but must do so under a performance improvement plan due to a decrease in job performance as a result of his PTSD. He also reported that he completed his course work for a MSW degree, but that he has not yet taken the LCSW examination. The Board acknowledges that the medical evidence indicates that the Veteran remains employed and was able to handle a degree program while working, but that the August 2012 VA examination report, as well as the Veteran's VA treatment records, include some indication that the Veteran has difficulty in adapting to stressful circumstances, particularly in a workplace setting, with symptoms such as difficulty concentrating, irritability, and recurrent intrusive thoughts. Nevertheless, the VA examiner also noted that it was unclear exactly how the Veteran's PTSD resulted in decreased performance at work. The TDIU claim is part and parcel of the increased rating claims on appeal, but the claim for TDIU has not yet been adjudicated by the RO. VA has a duty to assist the Veteran in the development of the claim. This duty includes assisting the Veteran in the procurement pertinent records and providing an examination when necessary. See 38 U.S.C.A. § 5103A(d)(1); 38 C.F.R. § 3.159(c)(4) (VA has an affirmative duty to obtain an examination of the claimant at VA health-care facilities if the evidence of record does not contain adequate evidence to decide a claim). Accordingly, the issue of TDIU is REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). Expedited handling is requested.) 1. Send the Veteran a VCAA notice letter pertaining to a claim for entitlement to TDIU, and allow for a reasonable period to respond. The RO/AMC should request that the Veteran provide sufficient information and authorization, to enable it to obtain any additional evidence pertinent to the claim for TDIU. The RO should assist the Veteran in obtaining any additional evidence identified by following the current procedures set forth in 38 C.F.R. § 3.159. All records/responses received should be associated with the claims file. If any records sought are not obtained, the RO should notify the Veteran of the records that were not obtained, explain the efforts taken to obtain them, and describe further action to be taken. 2. Schedule the Veteran for an appropriate VA examination to determine the current nature and severity of the Veteran's service-connected disabilities. Based on the review of the claims file, the examiner must provide an opinion as to whether the Veteran is unable to obtain or retain employment due to his service-connected PTSD, lumbar spine disability, right knee disabilities, onychomycosis and tinea pedis, right ankle sprain, and probable lipoma, consistent with his education and occupational experience, irrespective of age and any nonservice-connected disorders. A rationale for all opinions expressed should be provided. 3. When the development requested has been completed, as well as any other development required regarding the claim for TDIU, the RO/AMC should adjudicate the issue of TDIU. The purpose of this remand is to further develop the record and afford due process. The Board does not intimate any opinion as to the merits of the case, either favorable or unfavorable, at this time. The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ____________________________________________ K. J. ALIBRANDO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs